Comprehensive Healthcare Inspection Summary Report: Evaluation of Care Coordination in Veterans Health Administration Facilities, Fiscal Year 2021

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report highlights the results of a focused evaluation of Veterans Health Administration (VHA) facilities’ care coordination programs related to inter-facility patient transfers. The report describes findings from healthcare inspections performed at VHA medical facilities during fiscal year 2021. Each inspection involved interviews with key staff and reviews of clinical and administrative processes.The OIG found general compliance with some of the selected care coordination requirements. However, the OIG identified weaknesses with and issued four recommendations related to the• existence of facility policies for inter-facility transfers,• monitoring and evaluation of inter-facility transfers,• transmission of patients’ active medication lists and advance directives to receiving facilities, and• communication between nurses at sending and receiving facilities.